THE BONE MARROW ASPIRATION & BIOPSI

HARLINDA HAROEN

HEMATO-ONCOLOGY DIVISION INTERNAL MEDICINE DEPARTMENT SAM RATULANGI UNIVERSITY

MANADO

 Bone Marrow (BM) is one of the most widely distributed organs in the human body.

BM soft fatty tissue found inside the bodys larger bones. It has a honeycomb/ sponge-like structure consisting of a fibrous network that is filled with liquid.

Picture 1. Distribution of erythropoietic (red) marrow in the normal adult

 The liquid contains stem cells, blood cells in various stages of maturation iron, vit B-12 & folate for cell production. BM its the principal site of blood formation beginning at the time of birth all bone cavities filled with hematopoietic tissue. By adolescence, active marrow only found in the cavities of axial bones (sternum, ribs, vertebrae, clavicles, skull, pelvis & proximal ends femur & humeri.

 Overall BM cellurarity approximates 100% at birth with time (paralleling an age-associated reduction in hematopoietic activity). Accordingly BM cellularity in the N adult: 50% (remainder composed of adipose tissue). Physiologic conditions, all sites of hematopoiesis uniform cellularity & cell lineage proportions.

 Thus, generalization evaluation of BM at single site

In some hematologic disorders, study of BM at multiple sites hasnt been shown to improve D/ accuracy.

 Exceptions: malignancy patchy marrow involvement requiring larger specimens & specimens from multiple sites

BMAB provides information about the status of & capability for blood cell production

 BMAB usually regarded by the public & physicians as a brutal, extremely & painful procedure As with any invasive procedure BMAB best performed by trained clinicians. With knowledge & experience: succesfull marrow procedures minimal discomfort

 Bone Marrow Examination (BME) pathologic analysis of samples of BM obtain by BMAB. Peripheral blood examination & other routine lab. assays dont always provide enough information for D/ hematologic disorders. In some pts direct microscopic exam of the BM confirmation of a suspected clinical D/ or monitoring the course of medical Th/

 The decisions to subject a pts to BME after critical assessment of pertinent information available from history, physical & lab. BME usefull tool in the D/ & staging of various hematologic diss. & in the assessment of BM cellularity, cellular morphology, & maturation. Highly specialized testing cytogenetic, molecular analysis & immunophenotypic can be performed on these specimens.

 To accommodate blood cell formation, BM also houses of a stromal complex, along with elements of the monocyte-macrophage system supporting cellular system number of systemic diseases.

Accordingly BMAP & culture of BM have value in the assessment of FUO & in D/ of storage & infiltrative diseases

INDICATION BONE MARROW EVALUATION

- Evaluation of unexplained anemia, leukopenia, thrombocytopenia, or pancytopenia - D/ & staging of lymphoma & solid tumor. - Evaluation of peripheral counts ( eg, polycythemia)

INDICATION BONE MARROW EVALUATION - D/ & evaluation of plasma cell disorders & leukemias
- Evaluation of iron metabolism & stores. - Evaluation of suspected deposition & storage diseases. - Evaluation of FUO, suspected mycobacterial, fungal, or parasitic infections, or granulomatosis disease. - Unexplained splenomegaly.

INDICATION BONE MARROW EVALUATION

- Evaluation of suspected chromosomal disorders in

neonates. - Confirmation that the BM is N in a potential allogenic hematopoietic cell donor. - Marrow damage radiation, drugs, chemical & myelotoxic agents. - Determine the efficacy of Th/ & monitor recovery process in BM transplantation/chemotherapy

Figure 1. Clinical indication for a bone marrow evaluation

CONTRA-INDICATION (CI)
CI absolute: - hemophilia, severe disseminated intravascular coagulopathy, or other related severe bleeding disorders. CI relative: Infection Previous radiation at the same site Poor cooporation Sternal BMA dissease associated bone resorption (multiple myeloma) risk sternal perforation

CONTRA-INDICATION
Pts receiving anticoagulants: PT/ aPTT within N the Th/ range for warfarin/ heparin.
Isolated thrombocytopenia isnt c.indication: if the procedure properly performed technical difficulties are not encountered platelet transf. To insure platelet count > 20.000 may be warranted.

 Complications from the BM is rare (0,12-0.30%) : - trauma to neighboring structures & soft tissues - infection - hemorrhage - retroperitoneal hematomas - fractures (osteoporosis)

ASPIRATION & BIOPSY SITE

The posterior superior iliac crest & spine is the favored site. The anterior iliac crest may used in adult when acces to the posterior iliac crest is limited. In selected cases greater trochanter of the femur, individual vertebral bodies, or ribs. BM maybe aspirated from the sternum (biopsy at this site is CI) penetration sternum/ rib interspace fatal hemorrhage.

Dry Tap
Dry tap situation in which no BM sample is obtainable by aspiration.
Faulty technique maybe the cause the tip of aspirating needle may not have penetrated into marrow cavity. More often myeloproliferative or leukemic disorder such marrow changes usually involve an element of fibrosis, metastatic tumor infiltration or granuloma.